Emergency Medical Technician in the United States

Emergency medical technicians

When a medical emergency occurs — a traffic accident with injuries, a heart attack, a baby being born before the mother can reach the proper medical facilities — the first people to arrive on the scene to provide medical assistance usually aren’t doctors. They’re emergency medical technicians, or EMTs. EMTs don’t have medical degrees and aren’t qualified to perform all of the lifesaving tasks that many hospital personnel are, but they have enough medical knowledge to stabilize a patient, perform basic lifesaving tasks and transport them safely to a hospital where more advanced equipment and qualified doctors and nurses can do the rest. When you call for an ambulance, EMTs are the people who are going to get out when it arrives.

Emergency Medical Technician in the United States. Image: www.lanecc.edu

Emergency medical technician (EMT) or ambulance technician are terms used in some countries to denote a health care provider of emergency medical services.EMTs are clinicians, trained to respond quickly to emergency situations regarding medical issues, traumatic injuries and accident scenes.

EMTs are most commonly found working in ambulances, but should not be confused with “ambulance drivers” – ambulance staff who in the past were not trained in emergency care or driving. EMTs are often employed by ambulance services, governments, and hospitals, but are also sometimes employed by fire departments (and seen on fire apparatus), in police departments (and seen on police vehicles), and there are many firefighter/EMTs and police officer/EMTs. EMTs operate under a limited scope of practice. EMTs are typically supervised by a medical director, who is a physician.

Some EMTs are paid employees, while others (particularly in rural areas) are volunteers.

History

EMT program in the United States began as part of the “Alexandria Plan” in the early 70’s, in addition to a growing issue with injuries associated with car accidents. Emergency medicine (EM) as a medical specialty is relatively young.

Prior to the 1960s and 70s, hospital emergency departments were generally staffed by physicians on staff at the hospital on a rotating basis, among them general surgeons, internists, psychiatrists, and dermatologists. Physicians in training (interns and residents), foreign medical graduates and sometimes nurses also staffed the Emergency Department (ED).

EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic emergency departments (EDs) of the time. During this period, groups of physicians began to emerge who had left their respective practices in order to devote their work completely to the ED. The first of such groups was headed by Dr. James DeWitt Mills who, along with four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade, and Dr. Steven Bednar at Alexandria Hospital, VA established 24/7 year round emergency care which became known as the “Alexandria Plan”.

It was not until the establishment of American College of Emergency Physicians (ACEP), the recognition of emergency medicine training programs by the AMA and the AOA, and in 1979 a historical vote by the American Board of Medical Specialties that EM became a recognized medical specialty. The nation’s first EMT’s were from the Alexandria plan working as Emergency Care Technicians serving in the Alexandria Hospital Emergency Room.

The training for these technicians was modeled after the established “Physician Assistant” training program and later restructured to meet the basic needs for emergency pre-hospital care. On June 24, 2011, The Alexandria Hospital Celebrated the 50th Anniversary of the Alexandria Plan. In attendance were three of the nation’s first ECTs/EMTs: David Stover, Larry Jackson, and Kenneth Weaver.

Certification

In the United States, EMTs are certified according to their level of training. Individual states set their own standards of certification (or licensure, in some cases) and all EMT training must meet the minimum requirements as set by the National Highway Traffic Safety Administration’s (NHTSA) standards for curriculum.The National Registry of Emergency Medical Technicians (NREMT) is a private organization which offers certification exams based on NHTSA education guidelines. Currently, NREMT exams are used by 46 states as the sole basis for certification at one or more EMT certification levels. A NREMT exam consists of skills and patient assessments as well as a written portion.

The Veteran Emergency Medical Technician Support Act of 2013, H.R. 235 in the 113th United States Congress, would amend the Public Health Service Act to direct the Secretary of Health and Human Services to establish a demonstration program for states with a shortage of emergency medical technicians to streamline state requirements and procedures to assist veterans who completed military EMT training while serving in the Armed Forces to meet state EMT certification and licensure requirements. The bill passed in the United States House of Representatives, but has not yet been voted on in the United States Senate.

Levels

The NHTSA recognizes four levels of EMTs:

EMT-B (Basic)

EMT-I/85 (Intermediate)

EMT-I/99 (Intermediate)

EMT-P (Paramedic)

Some states also recognize the Advanced Practice Paramedic or Critical Care Paramedic level as a state-specific licensure above that of the Paramedic. These Critical Care Paramedics generally perform high acuity transports that require skills outside the scope of a standard paramedic. In addition, EMTs can seek out specialty certifications such as Wilderness EMT, Wilderness Paramedic, Tactical EMT, and Flight Paramedic.

Transition to new levels

In 2009, the NREMT posted information about a transition to a new system of levels for emergency care providers developed by the NHTSA with the National EMS Scope of Practice project.By 2014, these “new” levels will replace the fragmented system found around the United States. The new classification will include emergency medical responder (replacing first responder), emergency medical technician (replacing EMT-Basic), advanced emergency medical technician (replacing EMT-Intermediate 1985), and Paramedic (replacing EMT-Intermediate 1999 and EMT-Paramedic). Education requirements in transitioning to the new levels are substantially similar.

EMT-B

EMT-Basic is the entry level of EMS. The procedures and skills allowed at this level are generally non-invasive such as bleeding control, positive pressure ventilation with a bag valve mask, oropharyngeal airway, nasopharyngeal airway, supplemental oxygen administration, and splinting (including full spinal immobilization). Training requirements and treatment protocols vary from area to area.

Intermediate levels of EMT

EMT-Intermediates are the levels of training between basic (EMT-B) and Paramedic (EMT-P). There are two intermediate levels that are tested for by the NREMT, the EMT-I/85 and the EMT-I/99, with the 1999 level being the more advanced of the two. The standard curriculum for EMT-I from 1998 is defined by the NHTSA, but each state may not have implemented or approved this program. Many states have stopped issuing new Intermediate licensure, instead focusing on maintaining the current lists of intermediates they have, and encouraging the Basic to Paramedic program philosophy. Outside of the NHTSA framework, some states have instituted their own intermediate EMT levels using a variety of names (e.g. Advanced EMT in California or the levels of Advanced EMT-Intermediate and Advanced EMT-Critical Care in New York).

EMT-I/85

EMT-I/85 is a level of training that will typically allow several more invasive procedures than are allowed at the basic level, including IV therapy, the use of multi-lumen airway devices (even endotracheal intubation in some states), and provides for enhanced assessment skills.

EMT-I/99

The EMT-I/99 represents a higher level than the EMT-I/85 with an expanded scope of practice, such as cardiac monitoring and the administration of additional pharmaceutical interventions, as well as additional training time.

EMT-P

EMT-Paramedics, who are commonly referred to as simply “Paramedics”, represents the highest level of EMT, and in general, the highest level of prehospital medical provider, though some areas utilize physicians as providers on air ambulances or as a ground provider. Paramedics perform a variety of medical procedures such as fluid resuscitation, pharmaceutical administration, obtaining IV access, cardiac monitoring (continuous and 12-lead), and other advanced procedures and assessments.

Staffing levels

An ambulance with only EMT-Bs is considered a Basic Life Support (BLS) unit, an ambulance utilizing EMT-Is is dubbed an Intermediate Life Support (ILS) unit, and an ambulance with Paramedics is dubbed an Advanced Life Support (ALS) unit. Some states allow ambulance crews to contain a mix of crews levels (e.g. a basic and a Paramedic or an intermediate and a Paramedic) to staff ambulances and operate at the level of the highest trained provider. There is nothing stopping supplemental crew members to be of a certain certification, though (e.g. if an ALS ambulance is required to have two Paramedics, then it is acceptable to have two Paramedics and a basic).

Education and training

EMT training programs for certification vary greatly from course to course, provided that each course at least meets local and national requirements.

In the United States, EMT-Bs receive at least 110 hours of classroom training, often reaching or exceeding 120 hours. EMT-Is generally have 200–400 hours of training, and EMT-Ps are trained for 1,000 hours or more. In addition, a minimum number of continuing education (CE) hours are required to maintain certification. For example, to maintain NREMT certification, EMT-Bs must obtain at least 48 hours of additional education and either complete a 24 hour refresher course or complete an additional 24 hours of CEs that would cover, on an hour by hour basis, the same topics as the refresher course would. Recertification for other levels follows a similar pattern.

EMT training programs vary greatly in calendar length (number of days or months). For example, fast track programs are available for EMT-Bs that are completed in two weeks by holding class for 8 to 12 hours a day for at least two weeks. Other training programs are months long, or up to 2 years for Paramedics in an associates degree program.

In addition to each level’s didactic education, clinical rotations may also be required (especially for levels above EMT-Basic). Similar in a sense to medical school clinical rotations, EMT students are required to spend a required amount of time in an ambulance and on a variety of hospital services (e.g. obstetrics, emergency medicine, surgery, psychiatry) in order to complete a course and become eligible for the certification exam. The number of clinical hours for both time in an ambulance and time in the hour vary depending on local requirements, the level the student is obtaining, and the amount of time it takes the student to show competency. EMT training programs take place at numerous locations, such as universities, community colleges, technical schools, hospitals or EMS academies.

Every state in the United States has an EMS lead agency or state office of emergency medical services that regulates and accredits EMT training programs. Most of these offices have web sites to provide information to the public and individuals who are interested in becoming an EMT.

Free EMT practice test:

Take our the following EMT practice test to prepare for your National Registry of Emergency Medical Technicians Exam:

Medical direction

In the United States, an EMT’s actions in the field are governed by state regulations, local regulations, and by the policies of their EMS organization. The development of these policies are guided by a physician medical director, often with the advice of a medical advisory committee.

In California, for example, each county’s Local Emergency Medical Service Agency (LEMSA) issues a list of standard operating procedures or protocols, under the supervision of the California Emergency Medical Services Authority. These procedures often vary from county to county based on local needs, levels of training and clinical experiences.

New York State has similar procedures, whereas a regional medical-advisory council (“REMAC”) determines protocols for one or more counties in a geographical section of the state.

Treatments and procedures administered by Paramedics fall under one of two categories, off-line medical orders (standing orders) or on-line medical orders. On-line medical orders refers to procedures that must be explicitly approved by a base hospital physician or registered nurse through voice communication (generally by phone or radio) and are generally rare or high risk procedures (e.g. rapid sequence induction or cricothyrotomy).

In addition, when multiple levels can perform the same procedure (e.g. AEMT-Critical Care and EMT-Paramedics in New York), a procedure can be both an on-line and a standing order depending on the level of the provider. Since no set of protocols can cover every patient situation, many systems work with protocols as guidelines and not “cook book” treatment plans.

Finally, systems also have policies in place to handle medical direction when communication failures happen or in disaster situations. The NHTSA curriculum is the foundation Standard of Care for EMS providers in the US.

Employment

EMTs are employed in varied settings ranging from industrial and entertainment positions to hospital and health care settings, and the prehospital environment. The prehospital environment is loosely divided into non-emergency (e.g. hospital discharges) and emergency (9-1-1 calls) services, but many ambulance services operate both non-emergency and emergency care.

In many places across the United States, it is not uncommon for the primary employer of EMTs (both EMT-Ps and EMT-Bs) to be the fire department, with the fire department providing the primary emergency medical system response. In other locations, such as Boston, Massachusetts, emergency medical services are provided by a separate, or “third-party”, government agency. In still other locations, emergency medical services are provided by volunteer agencies. College and university campuses may provide emergency medical responses on their own campus using students.

In some states of the US, many EMS agencies are run by Independent Non-Profit Volunteer First Aid Squads that are their own corporations set up as separate entities from fire departments. In this environment, volunteers are hired to fill certain blocks of time to cover emergency calls. These volunteers have the same state certification as their paid counterparts.